October is National Mental Health and Depression Screening month. And earlier this month, the US Preventative Task Force–a task force used by doctors which makes recommendations on preventative health measures like mammograms, colonoscopy screenings, and pap smears–released new recommendations for the screening of anxiety, depression, and suicide in children and teens.
Three key findings of the task force’s report include the following:
- Screening for major depressive disorder in teens ages 12-18 presents a moderate net benefit for young people, meaning the positive outcomes outweigh the possible risks.
- Screening for anxiety in youth ages 8-18 also presents a moderate net benefit.
- Not enough research to know if screening for suicide risk would be more helpful than harmful
The screening tests used to create these guidelines are based on questionnaires.
The task force reviewed commonly-used screening tool questionnaires from around the world to see if they worked and were beneficial for teens. At the end of this review, the Preventative Task Force found that screening for anxiety and depression is helpful in addressing teen mental health and should be implemented. It’s important to note that they did not specify when or how often questionnaires should be administered, though it’s safe to assume that annual check-ups with a pediatrician is the best place for these questions to be asked (most screenings studied in the research usually took place in a doctor or clinician's office).
Once a diagnosis is established clinicians may recommend further diagnostic testing. The ultimate hope is that children and teens will benefit from therapy, medication, or other early interventions based on a few simple questions sooner than later.
These recommendations come at a time when our country’s teens face a mental health crisis. More than one in three high school students reported persistent feelings of sadness or hopelessness in 2019. This is a 40% increase from 2009. And perhaps even more striking, almost one in sex youth reported making a suicide plan in 2019, a 44% increase when compared to 2019. Suicide is now the fourth leading cause of death across the world in teens 15 to 19.
When undiagnosed and untreated, these conditions have serious repercussions for the future. Anxiety disorders in children are associated with an increased likelihood of anxiety in the future. Likewise, major depressive disorder in children and teens is associated with recurrent depression in adulthood as well as other mental health disorders, an increased risk for suicidal ideation, and an increased risk of successful suicide attempts. For this reason, early screening and detection of mental health conditions is crucial.
In this post, we will discuss how depression and anxiety present in adolescents, what the new published guidelines mean for parents and clinicians, what screening questionnaires for depression and anxiety look like, and what you can do to better understand and care for your child.
Depression in Teens
The Diagnostics and Statistical Manual of Mental Disorders, the manual studied by all mental health clinicians, defines major depressive disorder as having at least 2 weeks of mild to severe persistent feelings of sadness or a lack of interest in activities once enjoyed.
In addition to feelings of sadness or loss of interest, depression often also presents with a cluster of the following symptoms:
- Sleep disturbances that may include sleeping too much or too little
- Feelings of guilt, worthlessness, or failures of the past
- Fatigue and lack of energy even after small tasks
- Difficulties with concentration, thinking, memory
- Loss of appetite and weight loss or the opposite: increases in appetite and weight gain
- Slowed thinking, speaking, or bodily movements
- Suicidal behavior which includes thinking about suicide, attempting suicide, or completing suicide
- Irritability or angry outbursts even over small matters
- Physical symptoms like headaches, stomach aches, or back aches
Although the guidelines suggest screening for all children and teens ages 12-18, certain children and teens may be at higher risk for depression, even if they are not showing symptoms. Give careful consideration to your teen if they are someone with:
- A family history of depression
- A prior episode of depression
- Other mental health or behavioral concerns including, for example, anxiety or obsessive compulsive disorder
- Exposure to traumatic events like genocide or domestic abuse
- A history of bullying either as either the perpetrator of the victim
- Adverse life events, such as a death of a loved one, parental divorce, or parental military service
- Early exposure to child mistreatment in the form of physical abuse, emotional abuse, sexual abuse, neglect, or more
- Inconsistent parental relationships, for example, a history of a parent who was insensitive or unpredictable with their childcare
Anxiety in Children and Teens
Anxiety disorder is a group of related conditions defined by excessive fear or worry. There are 7 different types of anxiety disorders in children and adolescents defined in the Diagnostic and Statistical Manual of Mental Disorders. These include:
- Generalized anxiety disorder, which primarily involves excess worry about everyday issues and circumstances
- Social anxiety disorder, which is characterized by anxiety surrounding everyday social interactions
- Panic disorder resulting in sudden panic attacks
- Agoraphobia, which is defined by a fear of leaving the house or crowded environments
- Specific phobias such as example to planes, insects, needles, heights or more
- Separation anxiety disorder, which can be identified through excessive anxiety surrounding separation from family or loved ones
- Selective mutism, which is often seen in children who cannot speak at school or away from the house
Like with depression, certain teens may be more predisposed to developing anxiety. Pay special attention to your teen if they have:
- Difficulty with emotionally attaching to others or relating to others
- Witnessed strong verbal disagreements or physical violence between parents
- Parents or guardians who are controlling
- Parents who separated at an early age
- Experienced mistreatment in the forms of physical abuse, emotional abuse, sexual abuse, or neglect
- Experienced poverty or comes from a low socioeconomic status
Additionally, the National Survey on LGBTQ Youth Mental Health reported that 72% of lesbian, gay, bisexual, transgender, and queer youth and 77% of trasngender and nonbinary youth described symptoms of generalized anxiety disorder. If your child or teen is a part of the LGBTQIA+ community, paying special attention to their mental health and mental health screenings could be useful.
What are mental health screening tests?
The U.S. Preventative Services Task Force states there is a moderate benefit to the screening of all adolescents ages 12-18 for major depressive disorder and a moderate benefit to the screening of all children and teens 8-18 for anxiety. It’s important to note that these preventative recommendations are for those who do not have a diagnosed disorder and are not showing recognized signs or symptoms of these conditions.
But what do screening tests actually entail?
Screening questionnaires are provided to children and teens in a clinician's office. After completion, the screening questionnaires are scored. The score allows clinicians to determine whether the child or teen needs additional diagnostic testing and treatment.
Although many screening test questionnaires can be used in practice, the ones discussed by name in the new guidelines are explained below, including examples of potential questions:
Screening for major depressive disorder:
The 9-item Patient Health Questionnaire (PHQ-9) and the full Patient Health Questionnaire modified for adolescents (PHQ-A) screen for major depressive disorder.
- Respondents are asked to answer how often they have been bothered by problems like “little interest or pleasure in doing things,” “feeling tired or having little energy,” or “trouble concentrating” in the last two weeks.
- Teens then respond “not at all,” “several days,” “more than half the days,” or “nearly every day” to these statements. A few additional questions at the end complete the survey.
The Center for Epidemiologic Studies Depression Scale (CES-D), also named in the new guideline, also screens for major depressive disorder.
- Survey respondents are asked to answer how often they agree with statements like “I felt depressed” or “I was happy” in the past week.
- Participants answer “rarely,” “1-2 days,” “3-5 days,” or “5-7 days.”
Although there was insufficient evidence to officially recommend screening for suicidal ideation, most depression screening tests do include at least one question or item related to this topic. For example, in the depression questionnaire, participants are asked to answer how often they have thoughts of hurting themselves or thoughts that they would be better off dead.
Screening for anxiety:
Screen for Child Anxiety Related Disorders (SCARED) is a questionnaire that tests for global anxiety and any anxiety disorder.
- This questionnaire consists of one part to be filled out by the child and another complimentary part to be filled out by the parent.
- Children and parents answer “not true,” “somewhat true,” or “very true” to a number of statements.
- Sample statements for children include “I am nervous,” “I worry about going to school,” or “I am afraid of having anxiety or panic attacks.” The parent compliment to these questions would be “My child is nervous,” My child worries about going to school,” and “My child is afraid of having anxiety or panic attacks,”
Social Phobia Inventory (SPIN) screens for social anxiety disorder.
- Respondents read statement such as “Parties and social events scare me,” “I would do anything to avoid being criticized,” or “I am afraid of doing things when people might be watching,”
- After reading statements, children and adolescents answer “not at all,” “a little bit,” “somewhat,” “very much,” or “extremely” to show how much they agree with each statement.
Many other screening tests may be deployed by clinicians to determine mental health needs. The ones above happen to be some of the most widely used. After completion, certain scores may indicate to a clinician that a child or teen is within a normal range of mental health scores.
Other scores may reflect that a child or teen should be referred for more complete testing. Once diagnosed, parents, teens, and clinicians can work together to develop a treatment plan to help the teen manage their depression or anxiety and feel more happiness, interest, and enjoyment. The treatment plan, agreed upon by the teen, parent, and clinician, might include therapy, lifestyle changes, medication, or other tools.
Limitations to the Guidelines
With any health intervention, moderate benefit comes with some risk. Furthermore, challenges in implementing these recommendations must be addressed.
Some initial limitations include:
False positive screening can lead to unnecessary referrals, unnecessary treatment, labeling, anxiety, or stigma. While the harm from psychological interventions are low, pharmacologic interventions like the introduction of medication in inappropriate patients can result in adverse effects.
Structural problems require systemic change
Many of the structural systems of power that are causing an increase in depression and anxiety amongst teens–climate change, racism, economic recession, poverty, and more–cannot be easily “solved,” even with a teen is connected to therapy and a supportive environment. Working on an individual and systemic level are both required to combat the mental health crisis our adolescents currently face as a whole.
Time crunches in clinician offices
Primary care physicians and pediatricians, burdened with many existing tasks, may not have the time to administer questionnaires and accurately guide parents on findings in the 15-20 minute appointment slots they are often assigned. Additionally, the published guidelines are recommendations but have no implementation power. Primary care or pediatrician offices with more staff and resources may be the ones to voluntarily take the lead on this initiative while offices with fewer resources may not have the ability. Could this widen an already existing gap based on socioeconomic status?
Despite these limitations, these guidelines are a good first step for parents and clinicians to think about how to take action against a crisis that is very real. And this action can start at home.
How can parents help at home?
All of the screening tests listed above are readily available online and could be administered at home. But should there be? There are no guidelines yet published regarding whether parents should administer these questionnaires to their children at home. Instead, parents can check in with and advocate for their children in the following ways:
- Encourage your child to share their feelings and validate them. Ask directly about depression, anxiety, or suicidal thoughts, using questions from the questionnaires as examples if needed. Listen to their thoughts without judgment or negative reactions.
- Support your child with comfort when they are sad, and with specific praise when you see them do something well. Parental warmth has been shown to reduce depression, psychological disorders, externalizing behaviors, and behavioral problems among youth. Additionally, these types of gestures can make youth feel less isolated.
- Be aware of your child or adolescent day to day. Reviews of many studies have shown that when parents know about their teens' activities, whereabouts, and friends, teens are at a lower risk for depression.
- Promote routine family activities like eating dinner together or completing a project together. These activities promote adolescents’ senses of identity, create family cohesion, and can help families get through difficult times.
- Reach out to your pediatrician or family medicine physician’s office to ask if depression and anxiety screening will be offered at their child’s next appointment. Ask if and how you can get involved in screening your child for depression or anxiety.
Mental Health Support at Charlie Health
If your teen has been screened for anxiety, depression, or suicidal ideation with results indicating they need a higher level of support, there are resources to help. While your options might feel overwhelming or too difficult to access (whether treatment programs are too far, have long waitlists, or don’t seem to be the right fit), Charlie Health’s virtual Intensive Outpatient program is designed to meet you and your teen exactly where you are. With personalized therapy multiple times per week from the comfort of home, virtual IOP may be the next step forward in ensuring sustainable healing and resiliency.